HomeMy WebLinkAbout4238 GEMSTONE LN - APPLICATIONS - 10/14/2014Ciof
F®rf CoRins
Planning, Development & Transportation
281 N. College Ave P.O. Box 580
Fort Collins, CO 80524
Phone 970-416-2740. Fax 224-6134
OVER-THE-COUNTER PERMITS ONLY
This application is to be used to apply for the following permits only (check all that apply). ❑ Air Conditioning
❑ Demolition (interior non-structural) ❑ Electrical Alteration (not service change) ❑ Gas Lighter ❑ Gas Log
❑ Heating Unit ❑ Lawn Sprinkler ❑ Mobile Home replacement �jRooting ❑ Sewer Line ❑ Photo -voltaic
❑ Ventilation ❑ Water Heater ❑ Water Line ❑ Wood/Pellet Stove (must be EPA certified, provide make, model and
manufacturer).
Complete all applicable information on the application. Incomplete applications will not be accepted.
Application # PSI ul lrsi� Date (A I
For office use only
Address(required)
Value of Construction (labor, materials, profit)
NZS �Z
kJobte
y Owner Name Address
City/State Zip
Phone
Applicant Name Address
City/State Zip
Phone
Contractor Address
City/State Zip
Phone
4 �- 'A-11 _1WryX
MN SS331
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Contractor City of Ft. Collins Sales Tax #
Are you paying taxes here or by report?
❑ Here ❑ Report
Sales tax number is required by all contractors
Are you paying with your trust account?
❑ Yes ❑ No
12 1 2_�oi�;q
Is this a residential or commercial project? lO Residential ❑ Commercial
If residential, is it: ❑ Single Family Detached PV-ondo/townhome (single family attached) ❑ Duplex
❑ Multifamily (apartment) ❑ Garage
If commercial, is it: ❑ Bank ❑ Bar ❑ Church ❑ Hotel/Motel ❑ Medical office ❑ Office ❑ Retail
❑ Restaurant ❑ Other (explain)
Is this building 50 years of age or more? ❑ Yes KNo If yes, you may need to contact Historic Preservation
If this is for a demolition permit, what year was the building constructed? K)/ A
If prior to 1975, you will need an asbestos assessment to submit with this application.
Description of work '' 0c V*Xz
*If lawn sprinkler/backflow preventer, must list licensed plumber. If first-time A/c, must list licensed electrician.
Subcontractors: List the company name or Gty of Ft Collins license 4 N4-F CA0'JTKACtJrJG/-F-n►c-
Electrician Plumber Mechanical Roofer )G Other
I hereby acknowledge that I have read this application and state that the above information is complete and correct. I agree to
comply with all requirements contained herein and city ordinances and state laws regulating building construction. I know that a
permit is not valid until it has been paid and issued.
Applicant:
Print Nam
Date lot Iq/1